In the past 18 months, several codes have moved through the Current Procedural Terminology process, valuation by the Relative-value Update Committee and publication in the 2006 Medicare fee schedule. These codes include spinal incision and drainage, vertebral augmentation after cavity creation (kyphoplasty) and intracranial stenting. This Coding Corner will examine the new category I codes for 2006 as well as their valuation in relative value units, or RVUs, since Medicare payment is determined by a code’s RVUs multiplied by the conversion factor. The deletion of several evaluation and management codes also will be addressed.
The American Academy of Orthopaedic Surgeons requested the development of spinal incision and drainage codes to parallel similar codes that exist for extremity joints. After collaboration with the AANS, CNS and North American Spine Society, a pair of codes was developed to describe posterior incision and drainage of a subfascial infection. Code 22010 (21.69 facility RVUs) reflects posterior drainage of a subfascial cervicothoracic abscess, whereas code 22015 (21.50 facility RVUs) described the same procedure in the lumbosacral region. Neither code should be reported with instrumentation removal (codes 22850 and 22852) or drainage of a complex postoperative wound (code 10180, 4.59 facility RVUs), which was the only code available for this procedure before 2006.
AANS and CNS Call for New Kyphoplasty Codes
The AANS and CNS requested the development of codes to reflect vertebral augmentation after cavity creation and/or fracture reduction (kyphoplasty). Although similar codes for vertebroplasty were developed years earlier, the AANS and CNS requested a new set of codes to reflect the additional work of balloon kyphoplasty. Code 22523 (16.29 facility RVUs) reflects percutaneous vertebral augmentation, including cavity creation and biopsy, using a mechanical device in the thoracic spine. The code will be used once in an operative session, even if bilateral access is obtained. Additional levels of kyphoplasty performed in either the thoracic or lumbar spine would be coded 22525 (7.47 facility RVUs). If only lumbar vertebrae are treated, then the primary code used would be 22524 (15.61 facility RVUs). Although previously reimbursed at 50 percent more than vertebroplasty by some payers under the unlisted code 22899, the survey process revealed only an incremental difference in physician work when comparing intraoperative work for vertebroplasty and kyphoplasty.
If the surgeon uses image guidance, the supervision and interpretation of the imaging is to be separately reported. The imaging codes for vertebroplasty were revised to include kyphoplasty as well. Code 76012-26 (1.88 facility RVUs) would be used for guidance by fluoroscopy, whereas code 76013-26 (1.93 facility RVU) would be used for computed tomographic guidance. The modifier -26 is appended when the surgeon does not own the equipment, but rather is only providing the professional component of the service. A radiology report must be dictated to reflect the supervision and interpretation of the radiological procedure, but it may be included in the operative note as a separate and distinct paragraph. Alternatively, a completely separate radiology report may be dictated.
A series of five endovascular treatment codes also was developed to reflect recent innovations in intracranial endovascular procedures. Code 61630 describes intracranial balloon angioplasty, whereas 61635 describes placement of an intracranial stent including balloon angioplasty, if necessary. Both codes include all selective vessel catheterization and diagnostic imaging including supervision and interpretation of the images obtained. For treatment of vasospasm, code 61640 describes balloon dilatation on the initial vessel in vasospasm, whereas 61641 reflects each additional vessel treated in the same vascular family and 61642 each additional vessel in a different vascular family. Likewise, the selective vessel catheterization and diagnostic imaging including supervision and interpretation of the images is included. Unfortunately, the Centers for Medicare and Medicaid Services have identified these as non-covered services and did not publish RVU values.
Redundant E&M Codes Eliminated
In addition, several evaluation and management codes have been eliminated for 2006. Three follow-up inpatient consultation codes (99261-99263) will now be reported as subsequent hospital care (99231-99233). The former codes were felt to be redundant with the subsequent hospital care codes, which will now be used for any subsequent E&M service provided after an inpatient consultation (99251- 99255). Similarly, the confirmatory consultation codes (99271-99275) will now be reported as an outpatient consultation (99241-99245). The confirmatory consultation codes were also deemed redundant. If a third-party payer requests the consultation, the -32 mandated services modifier should be appended to the outpatient consultation code.
Note that although the codes become valid on Jan. 1, it can take payers as long as six months to recognize the new changes.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is co-chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing Physicians Advisory Council, and he plans and instructs coding courses for the AANS and the North American Spine Society.